Provider Demographics
NPI:1558408401
Name:LARSEN, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17503 W PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-5021
Mailing Address - Country:US
Mailing Address - Phone:623-537-5119
Mailing Address - Fax:
Practice Address - Street 1:17503 W PERSHING ST
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-5021
Practice Address - Country:US
Practice Address - Phone:623-537-5119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11958101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ171878OtherAHCCS
AZ11958OtherPROF FOSTER PARENT